Rates of Patient Safety Indicators (PSIs) Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years among VA Patients in the First.

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Volume 11, Issue 4, Pages (July 2011)

Volume 11, Issue 4, Pages (July 2011)

Volume 11, Issue 4, Pages (July 2011)

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Rates of Patient Safety Indicators (PSIs) Rates of Patient Safety Indicators (PSIs) among VA Patients in the First Two Years among VA Patients in the First Two Years Following ACGME Resident Hour Reform Following ACGME Resident Hour Reform Amy Rosen, Ph.D. Center for Health Quality, Outcomes and Economic Research, VA Center of Excellence, Bedford VAMC Boston University School of Public Health, Health Policy and Management Department, Boston, MA AcademyHealth ● June 2008 Supported by VA HSR&D IIR# and NHLBI ROI HL

Co-Investigators Susan Loveland, M.A.T. 1,2 Patrick Romano, M.D., M.P.H. 3 Kamal Itani, M.D. 4 Paul Rosenbaum, Ph.D. 5 Jeffrey Silber, M.D., Ph.D. 5,6,7,8 Orit Even-Shoshan, M.S. 6,7 Michael Halenar, B.A. 6,9 Yun Teng, M.S. 7 Jingsan Zhu, M.B.A. 6 Kevin Volpp, M.D., Ph.D. 5,6,7,8,9 1 Center for Health Quality, Outcomes and Economic Research, VA Center of Excellence, Bedford VAMC 2 Boston University School of Public Health, Health Policy and Management Department 3University of California at Davis, School of Medicine, Division of General Medicine and Center for Healthcare Policy and Research 4Boston VA Healthcare System and Boston University, Departments of Surgery 5University of Pennsylvania, The Wharton School 6University of Pennsylvania, School of Medicine 7Center for Outcomes Research, The Children’s Hospital of Philadelphia 8The Leonard Davis Institute of Health Economics, The University of Pennsylvania 9Center of Health Equity Research and Promotion, VA Center of Excellence, Philadelphia VAMC

ACGME duty hours regulations implemented on July 1, 2003 to improve safety Do duty hour regulations improve or worsen patients outcomes in more vs. less teaching-intensive hospitals? Previous work shows slight improvement in mortality for VA patients with common medical conditions Little evidence on the effect of ACGME on other outcomes Background

To investigate whether rates of the AHRQ Patient Safety Indicators (PSIs) changed following ACGME duty hour reforms in more vs. less teaching-intensive hospitals in VA. Hypotheses: (1) Rates of technical skill-based PSIs (e.g. iatrogenic pneumothorax) would improve (2) Rates of PSIs related to continuity of care (e.g. postoperative sepsis) would worsen (3) Rates of PSIs reflecting collaborative care (e.g. postoperative hip fracture) would not change Objectives and Hypotheses

All unique patients (n=828,534) admitted to acute-care VA hospitals (n=131) between July 1, 2000 and June 30, 2005 Index admission: first admission for which there was no prior admission eligible for a given PSI composite within 5 years Exclusions from VA inpatient data: Admissions to hospitals outside the US (n=41,928) Transfers from non-VA hospitals (n=31,049) Admissions spanning July 1, 2003 (n=6,809) Admissions for patients older than 90 years (n=11,398) Study Population

VA inpatient data files (VA Patient Treatment File) for diagnoses, age, gender, and discharge status Veterans Health Administration Support Service Center Occupancy Rate Reports for number of beds per hospital VA Office of Academic Affiliations for number of residents Pre-reform period: pre-year 3 (7/01/00-6/30/01), pre-year 2 (7/01/01-6/30/02), and pre-year 1 (7/01/01-6/30/03) Post-reform period: post-year 1 (7/01/03-6/30/04) and post-year 2 (7/01/04-6/30/05) Data Sources/Years

Measured by the resident-to-bed ratio (RTB ratio) Calculated as the number of interns plus residents divided by the mean number of operational beds Minor teaching: RTB ratio >0 - <0.25 Major teaching: RTB ratio > <0.60 Very major teaching: RTB ratio >0.60 Teaching Intensity

Technical Care (795,306 admissions) Iatrogenic pneumothorax Foreign body left in during procedure Accidental puncture or laceration Postoperative hemorrhage or hematoma Continuity of Care (339,504 admissions) Postoperative physiologic or metabolic derangement Postoperative pulmonary embolism/deep vein thrombosis (PE/DVT) Postoperative sepsis Collaborative Care (653,270 admissions) Postoperative hip fracture Postoperative respiratory failure Selected infections due to medical care PSI Composites

Multiple time series research design Conditional logistic regression models adjusted for age, gender, comorbidities, secular trends, baseline severity, and stratifying on hospital site Odds ratios measure the degree to which PSI composite rates change differently in more vs. less teaching-intensive hospitals Tested stability by eliminating patients admitted to hospitals in NY State and those patients admitted from nursing homes Analysis

Years Pre and Post Duty Hour Reform of 7/1/03 Pre-3Pre-2Pre-1Post-1Post-2 Academic Year Number Admissions , , , , ,516 Age (Mean) Mean # of Comorbidities COMPOSITE RATES Technical Care PSIs PSI Events Total Eligible Admissions % Rate , , , , , Continuity of Care PSIs PSI Events Total Eligible Admissions % Rate , , , , , Collaborative Care PSIs PSI Events Total Eligible Admissions % Rate , , , , , Description of VA Sample

Non-teaching (0) Minor Teaching (>0-0.25) Major Teaching ( ) Very Major Teaching (>0.6) N (%) of facilities 19 (14.50%) 32 (24.43%) 40 (30.53%) 40 (30.53%) N (%) of admissions 36,634 (3.90%) 144,294 (15.38%) 387,667 (41.32%) 369,683 (39.40%) Hospital Characteristics by Teaching Status in VA

Group 1 ( 0 )Group 2: (>0.0 - <=0.25)Group 3 (> <=0.6)Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

Group 1 ( 0 )Group 2: (>0.0 - <=0.25)Group 3 (> <=0.6)Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

Group 1 ( 0 )Group 2: (>0.0 - <=0.25)Group 3 (> <=0.6)Group 4 ( >0.6 ) Changes Over Time in Unadjusted PSI Composite Rates in More vs. Less Teaching-Intensive VA Hospitals

Technical Care Composite Continuity of Care Composite Collaborative Care Composite Odds Ratio (95% CI) Odds Ratio (95% CI) Odds Ratio (95% CI) Resident/bed ratio*post1 a 1.09 ( ) P= ( ) P= ( ) P= 0.48 Resident/bed ratio*post2 a 1.05 ( ) P= ( ) P= ( ) P= 0.04 Number of cases795,306339,504653,270 Adjusted Odds of PSI Composite Events After Duty Hour Reform in More vs. Less Teaching-Intensive VA Hospitals

Residents get more sleep, but there are also increased handoffs Residents can still work 30 hours straight Compliance may not be high Possible Explanations for No Major Changes in PSI Rates

Strengths National sample of patients from the VA Difference-in-difference approach to reduce likelihood of confounding Utilization of standardized measures of patient safety Limitations No clinical data for risk adjustment Limitations in using PSIs to measure patient safety Unmeasured confounding Strengths/Limitations

Rates of Technical Care PSI composite did not improve between more vs. less teaching-intensive hospitals over time Rates of Continuity of Care PSI composite did not worsen - we saw a slight trend in worsening rates in post-reform year 2 in more teaching-intensive hospitals Rates of Collaborative Care PSI increased slightly over time (only in post-reform year 2) in more teaching- intensive hospitals, marginally significant increase (p=0.04) Conclusions

Implementation of ACGME had no overall systematic impact on patient safety in more vs. less teaching- intensive hospitals Lack of improvement in any of the PSI composites suggests that more work is needed to improve safety Need to examine the effects of ACGME beyond first 2 years Need more data on facilitators and barriers to improvements in clinical outcomes Implications

Thank you!